Feasibility and effectiveness of a low cost campaign on antibiotic prescribing in Italy: community level, controlled, non-randomised trial

Giulio Formoso, Barbara Paltrinieri, Anna Maria Marata, Carlo Gagliotti, Angelo Pan, Maria Luisa Moro, Oreste Capelli, Nicola Magrini, LOCAAL Study Group, Dante Baronciani, Simona Di Mario, Matteo Morandi, Silvana Quadrino, Mauro Doglio, Maria Assunta Longo, Alessandra Mattiola, Anna Mirenzi, Manuela Olia, Massimiliano Laviola, Giuseppe Fattori, Valentina Solfrini, Paolo Barani, Massimo Bevini, Enrico Biagini, Roberto De Gesu, Margherita Di Pietro, Alfredo Ferrari, Maurizio Pontiroli, Mario Stancari, Lorenza Gamberini, Maria Angela Ghelfi, Carla Orsi, Maura Pagani, Mauro De Rosa, Maria Luisa De Luca, Guido Pedrazzini, Alberto Nico, Ettore Brianti, Bruno Bersellini, Maria Consolazione Coppola, Valter Corsi, Roberto Gallani, Carla Bertelli, Giovanna Negri, Rossella Emanuele, Massimo Fabi, Luisa Canovi, Silvana Casale, Livia Mosca, Giuseppe Franzan, Alessandro Merli, Fabrizio Piazza, Maria Zoppi, Valter Bernabucci, Biagio Marsala, Jorge Frascara, Guillermina Noel, Alessandra Salfi, Giulio Formoso, Barbara Paltrinieri, Anna Maria Marata, Carlo Gagliotti, Angelo Pan, Maria Luisa Moro, Oreste Capelli, Nicola Magrini, LOCAAL Study Group, Dante Baronciani, Simona Di Mario, Matteo Morandi, Silvana Quadrino, Mauro Doglio, Maria Assunta Longo, Alessandra Mattiola, Anna Mirenzi, Manuela Olia, Massimiliano Laviola, Giuseppe Fattori, Valentina Solfrini, Paolo Barani, Massimo Bevini, Enrico Biagini, Roberto De Gesu, Margherita Di Pietro, Alfredo Ferrari, Maurizio Pontiroli, Mario Stancari, Lorenza Gamberini, Maria Angela Ghelfi, Carla Orsi, Maura Pagani, Mauro De Rosa, Maria Luisa De Luca, Guido Pedrazzini, Alberto Nico, Ettore Brianti, Bruno Bersellini, Maria Consolazione Coppola, Valter Corsi, Roberto Gallani, Carla Bertelli, Giovanna Negri, Rossella Emanuele, Massimo Fabi, Luisa Canovi, Silvana Casale, Livia Mosca, Giuseppe Franzan, Alessandro Merli, Fabrizio Piazza, Maria Zoppi, Valter Bernabucci, Biagio Marsala, Jorge Frascara, Guillermina Noel, Alessandra Salfi

Abstract

Objectives: To test the hypothesis that a multifaceted, local public campaign could be feasible and influence antibiotic prescribing for outpatients.

Design: Community level, controlled, non-randomised trial.

Setting: Provinces of Modena and Parma in Emilia-Romagna, northern Italy, November 2011 to February 2012.

Population: 1,150,000 residents of Modena and Parma (intervention group) and 3,250,000 residents in provinces in the same region but where no campaign had been implemented (control group).

Interventions: Campaign materials (mainly posters, brochures, and advertisements on local media, plus a newsletter on local antibiotic resistance targeted at doctors and pharmacists). General practitioners and paediatricians in the intervention area participated in designing the campaign messages.

Main outcomes measures: Primary outcome was the average change in prescribing rates of antibiotics for outpatient in five months, measured as defined daily doses per 1000 inhabitants/day, using health districts as the unit of analysis.

Results: Antibiotic prescribing was reduced in the intervention area compared with control area (-4.3%, 95% confidence interval -7.1% to -1.5%). This result was robust to "sensitivity analysis" modifying the baseline period from two months (main analysis) to one month. A higher decrease was observed for penicillins resistant to β lactamase and a lower decrease for penicillins susceptible to β lactamase, consistent with the content of the newsletter on antibiotic resistance directed at health professionals. The decrease in expenditure on antibiotics was not statistically significant in a district level analysis with a two month baseline period (main analysis), but was statistically significant in sensitivity analyses using either a one month baseline period or a more powered doctor level analysis. Knowledge and attitudes of the target population about the correct use of antibiotics did not differ between the intervention and control areas.

Conclusions: A local low cost information campaign targeted at citizens, combined with a newsletter on local antibiotic resistance targeted at doctors and pharmacists, was associated with significantly decreased total rates of antibiotic prescribing but did not affect the population's knowledge and attitudes about antibiotic resistance.

Trial registration: ClinicalTrials.gov NCT01604096.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no individual support from any organisation for the submitted work aside from the Italian Medicines Agency grant (Bando AIFA 2008); no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work, which has not been scientifically influenced by the study sponsor in any way as well.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4793446/bin/forg011754.f1_default.jpg
Prescription of antibiotics in intervention and control area from June 2010 to March 2012. DDD=defined daily doses

References

    1. Weiss JA, Tschirhart M. Public information campaigns as policy instruments. J Pol Anal Manage 1994;13:82-119.
    1. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet 2010;376:1261-71.
    1. Huttner B, Goossens H, Verheij T, Harbarth S, on behalf of the CHAMP consortium. Characteristics and outcomes of public campaigns aimed at improving the use of antibiotics in outpatients in high-income countries. Lancet Infect Dis 2010;10:17-31.
    1. Second report from the European Commission to the Council of Europe, on the basis of Member States’ reports on the implementation of the Council recommendation (2002/77/ec) on the prudent use of antimicrobial agents in human medicine. .
    1. World Health Organization. The evolving threat of antimicrobial resistance. Options for action. WHO Press, 2012. .
    1. ECDC/EMEA joint technical report (2009). The bacterial challenge: time to react. .
    1. De Kraker MEA, Davey PG, Grundmann H, on behalf of the BURDEN study group. Mortality and hospital stay associated with resistant Staphylococcus aureus and Escherichia coli bacteremia: estimating the burden of antibiotic resistance in Europe. PLoS Med 2011;8:e1001104.
    1. Domenighetti G, Grilli R, Liberati A. Promoting consumers’ demand for evidence-based medicine. Int J Technol Assess Health Care 1998;14:97-105.
    1. Coenen S, Michiels B, Renard D, Denekens J, Van Royen P. Antibiotics prescribing for acute cough: the effect of perceived patient demand. Br J Gen Pract 2006;56:183-90.
    1. Ciofi degli Atti ML, Massari M, Bella A, Boccia D, Filia A, Salmaso S. Clinical, social and relational determinants of paediatric ambulatory drug prescriptions due to respiratory tract infections in Italy. Eur J Clin Pharmacol 2006;62:1055-64.
    1. Muller A, Coenen S, Monnet DL, Goossens H. European Surveillance of Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe, 1998-2005. Euro Surveill 2007;12:pii=3284.
    1. Huttner B, Harbarth S. Variations in outpatient antimicrobial use between and within countries: an ongoing mystery. Infection 2010;38:1-2.
    1. Masiero G, Filippini M, Ferech M, Goossens H. Socioeconomic determinants of outpatient antibiotic use in Europe. Int J Public Health 2010;55:469-78.
    1. Italian Observatory on Medicines working group. L’uso dei farmaci in Italia. [Use of pharmaceuticals in Italy.] National report January-September, 2011. Rome, December 2011.
    1. European Centre for Disease Prevention and Control. Antimicrobial resistance surveillance in Europe 2011. Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). ECDC, 2012. .
    1. Italian Observatory on Medicines working group. L’uso dei farmaci in Italia. [Use of pharmaceuticals in Italy.] National report 2010. Rome, July 2011.
    1. Arnold SR, Straus SE. Interventions to improve antibiotic prescribing practices in ambulatory care. Cochrane Database Systc Rev 2005;(4):CD003539.
    1. Ranji SR, Steinman MA, Shojania KG, Gonzales R. Interventions to reduce unnecessary antibiotic prescribing. A systematic review and quantitative analysis. Med Care 2008;46:847-62.
    1. Filippini M, González Ortiz LG, Masiero G. Assessing the impact of national antibiotic campaigns in Europe. Eur J Health Econ 2013;14:587-99.
    1. Campbell NC, Murray E, Darbyshire J, Emery J, Farmer A, Griffiths F, et al. Designing and evaluating complex interventions to improve health care. BMJ 2007;334:455-9.
    1. Craig P, Dieppe P, Macintyre S, Mitchie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008;337:979-83.
    1. Goossens H, Ferech M, Vander SR, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579-87.
    1. Belongia EA, Schwartz B. Strategies for promoting judicious use of antibiotics by doctors and patients. BMJ 1998;317:668-71.
    1. LOCAAL Study Group. Doctors and local media: a synergy for public health information? A controlled trial to evaluate the effects of a multifaceted campaign on antibiotic prescribing (protocol). BMC Public Health 2011;11:816.
    1. Kotler P, Zaltman G. Social marketing: an approach to planned social change. J Market 1971;35:3-12.
    1. Edgar T, Boyd SD, Palamé MJ. Sustainability for behaviour change in the fight against antibiotic resistance: a social marketing framework. J Antimicrob Chemother 2009;63:230-7.
    1. Costelloe C, Metcalfe C, Lovering A, Mant D, Hay AD. Effect of antibiotic prescribing in primary care on antimicrobial resistance in individual patients: systematic review and meta-analysis. BMJ 2010;340:1120-30.
    1. Guidelines for ATC classification and DDD assignment 2013. WHO Collaborating Centre for Drug Statistics Methodology, 2012.
    1. Sabuncu E, David J, Bernède-Bauduin C, Pépin S, Leroy M, Yves Boelle P, et al. Significant reduction of antibiotic use in the community after a nationwide campaign in France, 2002-2007. PLoS Med 2009;6:e1000084.
    1. Wutzke SE, Artist MA, Kehoe LA, Fletcher M, Mackson JM, Weekes LM. Evaluation of a national programme to reduce inappropriate use of antibiotics for upper respiratory tract infections: effects on consumer awareness, beliefs, attitudes and behaviour in Australia. Health Promot Int 2006;22:53-64.
    1. Bauraind I, Lopez-Lozano JM, Beyaert A, Marchal B, Seys F, Yane E, et al. Association between antibiotic sales and public campaigns for their appropriate use. JAMA 2004;292:2468-70.
    1. Lambert MF, Masters GA, Brent SL. Can mass media campaigns change antimicrobial prescribing? A regional evaluation study. J Antimicrob Chemother 2007;59:537-43.
    1. Belongia EA, Knobloch MJ, Kieke BA, Davis JP, Janette C, Besser RE. Impact of statewide program to promote appropriate antimicrobial drug use. Emerg Infect Dis 2005;11:912-20.
    1. Gonzales R, Corbett KK, Wong S, Glazner JE, Deas A, Leeman-Castillo B, et al: “Get Smart Colorado.” Impact of a mass media campaign to improve community antibiotic use. Med Care 2008;46:597-605.
    1. Shepperd S, Lewin S, Straus S, Clarke M, Eccles MP, Fitzpatrick R, et al. Can we systematically review studies that evaluate complex interventions? PLoS Med 2009;6:e1000086.
    1. Milandri M, Marchi M, Resi D, Moro ML. Progetto Bambini e antibiotici. I determinanti della prescrizione nelle infezioni delle alte vie respiratorie. [Children and antibiotics project: determinants of antibiotic prescription in upper respiratory infections.] Emilia-Romagna Regional Health Agency. Dossier 115-2005.
    1. Goosens H, Guillemot D, Ferech M, Schlemmer B, Costers M, van Breda M, et al. National campaigns to improve antibiotic use. Eur J Clin Pharmacol 2006;62:373-9.
    1. Thackeray R, Neiger BL, Keller H. Integrating social media and social marketing: a four-step process. Health Promot Pract 2012;13:165-8.
    1. Scientific Report of EFSA and ECDC. The European Union Summary Report on antimicrobial resistance in zoonotic and indicator bacteria from humans, animals and food in 2010. EFSA J 2012;10:2598 .

Source: PubMed

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